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CPG,# TO: OWE OF REVENUE AND RECOVERY • <br /> ACCOUNT TRANSMITTAL, <br /> ACCOUNT NO. DEPT.NO. REFERRz> O ' ))Y <br /> 026000.0 III^J <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TJ AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> HAI HUYNH <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1587 TURNPIKE RD STOCKTON CA 95206 209-948-0832 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4105 MIST TRAIL RD STOCKTON CA 95206 209-948-0832 <br /> USER REFERENCE NO. BILL TAT ICYCLE ISTATUS DATEI BMd CBM IN MONTHLY PAY AMT <br /> 14393 HAZMAT 1. 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $85.00 8q 1 P43009.01 <br /> 30 0142900 o Hazmat Penalty Fee $8.50 p8q04 00 .0 <br /> 8q42900,0 State Surcharge Fee $24.00 p8q <br /> p8q 1 014290010 Electronic Surcharge $25.00 p8q <br /> 80 1 014290010 8q P44009.0 <br /> 80 11 014290010 8q P43009.0 <br /> 80 11 0 2qOO.p I paqP4400 .0 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> PRIOR STREET CITY QT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TJ AUTO REPAIR 209-948-0832 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1587 TURNPIKE RD STOCKTON CA 95206 <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYERPHONENO <br /> TJ AUTO REPAIR 209-948-0832 <br /> EMPLOYER STREET CITY ST 71P r.0DF <br /> 1587 TURNPIKE R � CA 95206 <br /> kDRFPARED BYu.� CHECKED BY IDATECOL. 20 Brea! <br />